What are estrogen creams?

Premarin and Estrace cream are cream preparations containing conjugated estrogens that may be used for the vagina and vulvar tissues. These products come in a tube and often have plastic applicators to help with insertion. Many women find these products especially soothing to the irritated pelvic area. They have the added benefit that they can be tailored and managed individually using more or less of the product depending on your clinical situation.

The vulvar area, which is sensitive to estrogen levels, can become irritated and bothersome when hormonal levels are lowered. Women find estrogen creams especially comforting because they can be applied to the external pelvic area as well. The usual dosage is 2 to 4g (marked on the applicator) daily for 1 or 2 weeks, and then it is gradually reduced to one-half the initial dosage for a similar period. A maintenance dosage of approximately 1g can be used one to three times a week. It may be used after restoration of the vaginal lining has been achieved. You can attempt to discontinue or taper the medication during period of 3 to 6 months. Of course, if you experience any side effects or symptoms of vaginal bleeding while on the cream, you should speak with your healthcare provider. Newer lower doses have also been shown to be effective.

The food and drug administration has recently approved Duramed's (a subsidiary of Barr Pharmaceutical) synthetic, conjugated estrogen cream. It is a plant-derived local estrogen product that can be used for moderate to severe vaginal dryness and/or painful intercourse, both of which are symptoms of vulvar and vaginal atrophy often associated with the menopause.

The vulvar area, which is sensitive to estrogen levels, can become irritated and bothersome when hormonal levels are lowered.

An interesting new and exciting use for vaginal estrogen creams is in the field of sexual arousal and orgasms. Recently, I published a small case series of women who used estrogen cream applied to the clitoral tissue because of decreased arousal and increased time to achieve orgasm. These women experienced increased arousal and increased orgasmic intensity when they applied estrogen cream to the clitoris. It may be helpful for you to use cream in the clitoral region as well if you are suffering from clitoral atrophy or have changes in arousal or orgasm. Ask your healthcare professional today.

What are vaginal estradiol tablets and vaginal rings?

Intravaginal estrogens are applied to the vaginal tissues and many products are minimally absorbed. Some sexual health providers prefer to prescribe minimally absorbed local 17 beta estradiol tablets. Vaginally administered estrogens in small, topically applied doses can be well absorbed. Patients say that the tablets are also easy to use, sometimes less messy than cream preparations, and technically easier to insert than estrogen rings.

Sometimes vaginal estradiol rings are prescribed for older women who complain of vaginal dryness and painful penetration. It is important to note that not all vaginal estrogen rings are the same and that they vary with respect to absorption into systemic circulation. Many women find them convenient because the rings are placed within the vaginal vault and are not changed for several months. The lower-dose vaginal rings release 7.5 micrograms per day of estradiol; this dose produces a steady state of serum (blood) levels of 6-8 pg/mL. This dose can treat local complaints of vaginal dryness but is not sufficient to treat hot flashes or other menopausal symptoms.

According to the North American Menopause Society's recent position statement concerning local vaginal estrogens, rings may change position during bowel movements, douching, and intercourse; however, there is no need to remove the ring during intercourse. In clinical experience, some women and men find rings uncomfortable. There are no data reporting on possible allergy to the silasitic plastic ring. Thickening of the endometrium or endometrial hyperplasia usually does not occur until levels surpass 19 pg/mL. The routine addition of a progestational agent is often not used and neither is it customary to recommend.

It is important to recognize that all estrogen products carry a black box warning and may mention some of the risks or complications. Some of the rare side effects include possible blood clots (thromboembolic events), increased heart problems (cardiovascular events), an increase in breast cancer, and increased endometrial cancer if unopposed with a progestin. The long-term safety data on minimally absorbed local vaginal estrogen products use in cancer patients remain to be further studied. Talk with your clinician to analyze which one may be the right solution for you and your partner.

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